American Board of Applied Toxicology

Application for Credentials Review and Examination

Instructions: Please type all information. A completed electronic version of this document is due March 1. Submit 1 signed copy of this application to the Chair of the Credentialing committee by March 5. Two checks ($200 US dollars Application Fee and a $300 US dollars Testing Fee), made payable to the American Board of Applied Toxicology, must also accompany the application. Do not send a combined application and testing check, please submit two individual checks. If credentialing is denied for any reason, the $300 examination fee will be refunded.

For mailing instructions, please contact the Credentialing Committee Chair at . The Credentialing Committee Chair will contact you via email and/or phone with mailing instructions. Credentialing Committee Chair contact information can also be located on the AACT Website ABAT (non-members side) under the ABAT Contact Information tab.

Name:

Surname:

First:

Middle:

Corresponding Address:

Institution:

Street or POB:

City:

State:

Zip:

Telephone:

Work:

Home:

Formal Education:

Degree(s) Institution Field of Study Year

Pharm.D.

M.Sc.

B.Sc.

Other

Licensure:

State:

Profession:

License Number:

Licensure:

State:

Profession:

License Number:

Number of Years in Clinical Toxicology Practice / Education/Research:

Current Professional Position(s) -- (Include position, title and institutional affiliation):

Position:

Title:

Institution:

This detailed application must be completed thoroughly. This information will be used to evaluate your credentials and determine if you are qualified to sit for the examination of the American Board of Applied Toxicology (ABAT). Applications are reviewed using a uniform scale which assigns points for aspects of the applicant's contributions to or activities in clinical toxicology practice, education, research and professional leadership. Based upon the review of this application, an applicant is recommended for approval as a candidate for examination. Acceptance as a candidate does not commit ABAT to a specific examination date.

A scoring sheet is attached at the end of this application to allow the candidate to score themselves. All applicants MUST score at least a total of 40 points to even be considered for credentialing purposes. It is not necessary to provide a response to all questions. Descriptions of professional activities need to be specific and detailed enough so that a fair evaluation can be performed.

Read the entire application before attempting to complete it. Include all documentation in the application. Where needed, extra pages may be added to the application. Type your name at the top of each page.

1. Describe or list the type, length and preceptors for your formal training in clinical toxicology for your a.) postgraduate training program, b.) residency, c.) fellowship.

2. Describe or list the type, length, and preceptors for your informal training in clinical toxicology.

3. Indicate the percentage distribution of your time spent annually in clinical toxicology in each of these areas:

Practice % Education % Research % Administration %

4. Briefly describe (250 words or less) your present activities as they relate to clinical toxicology.

PRACTICE:

5. Maximum = 8. Do you routinely monitor and provide advice on the therapy of poisoning victims (e.g. poison center cases, manufacturer's input to a poisoning case, part of a multidisciplinary health care team, direct patient contact), or have you done so in the past? Please provide documentation to support your activities.

_______Yes _______No If Yes, describe:

Instructions for scoring: If the candidate is clearly involved in the routine assessment and care of poisoned patients via direct patient contact, participating in a multidisciplinary health care team, handling poisoning or overdose cases, score 6 points;


If the candidate is only sporadically involved in assessment and care of poisoned patients via direct patient contact, participating in a multidisciplinary health care team, award 3 points.


If the applicant is involved in reviewing completed cases or is a member of a multidisciplinary team only for his contribution to student or staff teaching and not patient care, award 3 points.


If the applicant’s primary patient evaluation and consultation activity is as only as a poison specialist, the maximum award is 1 point.


If the applicant personally provides written consults/progress notes on a routine basis, award an additional 2 points.


If the applicant personally provides written consults on an occasional basis, award an additional 1 point.

NOTE: In order to achieve the MAXIMUM points in this section, the applicant MUST be involved in the routine assessment of poisoning patients via direct patient contact AND provide written consults/progress notes to document those interactions.

If the applicant’s primary patient evaluation and written consultation activity is as a poison specialist, the maximum score they may achieve for question # 5 is 1 point.

6. Maximum = 2. Do you routinely provide education on poisoning to members of the lay community, or have you done so in the past (e.g. poison prevention education or individual counseling)? Please provide documentation to support your activities.

_______Yes _______No If Yes, describe:

Instructions for scoring: If the applicant communicates directly (this does NOT include telephone contact) with individual patients about poison prevention, award 1 point.


If the applicant participates in community education programs, or develops educational materials, award 1 point.


If the applicant only attends health fairs or hands out materials, award 0 points.

7. Maximum = 5. Do you provide expert witness testimony (i.e. testify at a trial or give a sworn deposition), in legal matters dealing with poisons or poisonings, or have you done so in the past? Please provide documentation to support your activities.

_______Yes _______No If Yes, describe:

Instructions for scoring: If the applicant has provided expert witness testimony to civil, criminal or appeals courts and has been recognized by the courts as an expert on more than three occasions, award 5 points.

If the applicant has provided expert witness testimony on less than three occasions, award 3 points.

If the applicant has produced reports for legal matters, but has not been recognized by the court as an expert witness (i.e. reviewing records but not testifying at trial or giving a sworn deposition), award 1 point.

8. Maximum = 5. Do you provide advice to governmental agencies (e.g. FDA, EPA, etc.), industry, or others on the regulatory aspects of toxicology issues (e.g. product labeling, material safety data sheets, toxicity testing), or have you done so in the past? Please provide documentation to support your activities.

_______Yes _______No If Yes, describe:


Instructions for scoring: If the applicant has provided written opinions to governmental agencies (e.g. FDA, EPA) for regulatory purposes on more than three occasions, award 5 points.


If the applicant has provided written opinions to governmental agencies (e.g. FDA, EPA) for regulatory purposes on less than three occasions, award 3 points.

If the applicant has provided written reports to drug or chemical manufacturers on more than three occasions, award 3 points.


If the applicant has provided written reports to drug or chemical manufacturers on less than three occasions, award 1 point.


If the applicant provides only oral reports, provide 0 points.

EDUCATION:

9. Maximum = 2. Do you serve as formal program director or major professor for one (or more) clinical toxicology residents, postgraduate trainees or visiting scientists, or have you done so in the past? Please provide documentation to support your activities.

_______Yes _______No If Yes, describe:

Instructions for scoring: If the applicant serves as a formal director for a residency/fellowship program or serves as a major professor for one (or more) clinical toxicology resident/fellow, post graduate trainee or scientist, award 2 points. NOTE: this criterion does NOT include precepting students or residents. Please see the section below for capturing precepting experience.

10. Maximum = 6. Do you have or have you had didactic and/or clinical responsibilities for the teaching of clinical toxicology to health professionals or health professional students? Please provide documentation to support your activities.

_______Yes _______No If Yes, describe:

Instructions for scoring: If the applicant developed and conducts more than three advanced toxicology didactic courses (or modules) on the graduate level, award 4 points.


If the applicant developed and conducts less than three advance toxicology didactic courses (or modules), award 2 points.


As above but on a B.S. level, award either 3 or 1 points.


If the applicant serves as a formal clinical clerkship teacher or preceptor for students (including role model practice), award 4 points.

If the applicant has contact with students but not as the formal teacher or preceptor, award 1 point.

11. Maximum = 3. Do you serve as an editor, editorial board member, or referee for health care or toxicology related publications, or referee for abstracts submitted to a toxicology related conference, or have you done so in the past? Please provide documentation to support your activities.

_______Yes _______No If Yes, describe:


Instructions for scoring: Editor or editorial board member of national – international publication award 2 points.

Editor or editorial board member of state publication, award 2 points

Editor or editorial board member of local publication, award 1 point

Referee for leading toxicology, biomedical or scientific journals, award 1 point

Abstract reviewer for scientific meeting, award 0.5 point.

12. Maximum = 4. Have you made any presentations (platform or poster) at professional meetings on subjects pertinent to clinical toxicology (including continuing education programs)? Please provide documentation to support your activities.

_______Yes _______No

If Yes, list the title, meeting, location and date:

Instructions for scoring: For every national or international presentation, award 1 point.

For every two state or regional meetings, award 1 point.

For every four local presentations (platform or poster) at professional meetings (CE or otherwise), award 1 point

13. Maximum = 5. Have you authored publications on toxicology practice or toxicology related matters? NOTE: Please do not include research publications at this time.

_______Yes _______No If Yes, indicate as follows:

A. Indicate the number of the following types of publications either previously published or currently in press (manuscripts submitted for publication and in preparation should not be included).

1. Books

2. Book chapters

3. Journal review articles, case reports

4. Letters to the editor or other scholarly activities

5. Other categories (newsletters, monographs, manuals, etc.)

B. Provide a complete list of the publications for categories 1-5 using standard National Library of Medicine (please see http://www.ashp.org/public/pubs/ajhp/procforsub.html for specific information on formatting) format. Precede each reference with the category number to which it applies. Indicate with the letter "R" which publications are refereed.


Instructions for scoring: For each book, book chapter, journal review article, or case report (NOTE: case reports are NOT considered research in the subsequent section) published in a national or international refereed clinical or scientific journal, award 1 point.

For each editorial, letter to the editor or article published in a non-refereed journal, award 0.5 points.

For newsletters and monographs award 0.5 points.

NOTE: The maximum score that can be obtained from publications of newsletters or monographs or other non-refereed publications is 2 points.

RESEARCH:

14. Maximum = 6. Are you, or have you been involved with the design, review, implementation, or monitoring of clinical toxicology or practice related research? Please provide documentation to support your activities.

_______Yes _______No If Yes, list each protocol and describe your role (e.g. Principal investigator, Collaborating Investigator, Reviewer, etc.) Indicate which protocols were funded.

Protocol Role Funded Y/N

Example Co-investigator Y

Instructions for scoring: Award 2 points for each protocol designed and implemented if the applicant was a principal investigator or project leader.

Award 1 point if co-investigator.


Add 0.5 point for each funded protocol.

15. Maximum = 14. Have you authored research reports on clinical toxicology related matters? Please provide documentation to support your activities.

_______Yes _______No If Yes, describe:


A. Indicate the number of the following types of research reports:

1. Research reports published in a scientific or clinical journal

2. Research abstracts published

3. Research reports prepared for a sponsoring or funding agency

B. On a separate page, provide a complete list of the research reports for categories 1-3. Precede each report with the number to which it applies.

Instructions for scoring: For each research paper published in a national or international refereed clinical or scientific journal, award 1 point if applicant is first author, 0.5 point if co-author.

For each research abstract published from any national or international clinical or scientific meeting, award 0.5 point if first author or co-author.

Award 1 point for each research report for a sponsoring agency. NOTE: this does NOT include standard reports to sponsoring agency.

LEADERSHIP:

16. Maximum = 5. Have you received any professional honors or awards? NOTE: Awards do not necessarily have to relate to toxicology but the award should relate to the applicants professional activities. Please provide documentation to support your activities.

_______Yes _______No If Yes, describe:

Instructions for scoring: Award 2 points for each national-international professional honor-award

Award 1 point for each state or regional award

Award 0.5 point for each local award.

17. Maximum = 5. Are you or have you been responsible for the establishment of a new toxicology service, education or research program? Please provide documentation to support your activities.

_______Yes _______No If Yes, describe:

Award 2 points for each new and innovative service, research or education program initiated by applicant. (The mere employment of the applicant by an institution would not alone constitute establishment of a new service).

18. Maximum = 3. Are you a member of any local, state, national or international health care, scientific or toxicology organizations? Please provide documentation to support your activities.

_______Yes _______No

If Yes, list the organizations and indicate committees that you have served on or offices that you have held in these organizations.


Award 0.5 point for membership in each national, international, state or local health care organization.

Award an additional 1 point for serving as an elected officer for any state, international or national organization.


Award 0.5 point for elected officer on local level and 0.5 point for committee member at any level.

19. Maximum = 2. Do you serve as a consultant to organizations on toxicology related matters, or have you done so in the past? Please provide documentation to support your activities.